E-IJD® - ORIGINAL ARTICLE
|Year : 2022 | Volume
| Issue : 4 | Page : 478
|Curcuma longa in the treatment of symptomatic oral lichen planus: A non-randomized controlled trial
Tanya Khaitan1, Vishal2, Arpita Kabiraj3, Dharmendra Kumar Sinha1, Rajeev Ranjan4, Rakhi Singh5
1 From the Department of Oral Medicine and Radiology and Prosthodontics, Crown and Bridge and Oral Implantology, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of Oral and Maxillofacial Surgery, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
3 Department of Oral Pathology and Microbiology, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India
4 Department of Pedodontics and Preventive Dentistry, Awadh Dental College and Hospital, Jamshedpur, Jharkhand, India
5 Department of Conservative Dentistry and Endodontics, Hazaribagh College of Dental Sciences and Hospital, Hazaribagh, Jharkhand, India
|Date of Web Publication||2-Nov-2022|
Department of Oral and Maxillofacial Surgery, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand-834 009
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Oxidative stress has been suggested as pathogenesis of oral lichen planus (OLP), implicating the vital role of antioxidants in its treatment. Curcumin, naturally found in turmeric has potent antioxidant and inflammatory properties and can be useful in reducing spread and subsiding burning and pain sensation in patients with OLP. The present study was done to evaluate the role of curcumin in the treatment of symptomatic OLP compared with the control group. Materials and Method: A total of 40 patients with symptomatic OLP were divided into 2 groups of 20 subjects each. Group A was treated with curcumin oral gel and a multivitamin capsule containing zinc, whereas Group B was given multivitamin containing zinc only. Patients were followed-up twice, that is, after 1 month and 3 months. A modified REU (reticulation/keratosis, erythema and ulceration) score for spread and Visual analogue scale for pain/burning sensation was used and the difference of score was calculated by t test. Results: During F1 period, 0.61 (Group A) and 0.19 (Group B) points improvement and in F2 period, the REU score further increased significantly to 1.36 (Group A) and 0.43 (Group B), respectively. The mean score reduction in Visual analogue scale during F1 period was 1.71 and 0.71, which further increased significantly to 2.88 and 1.24 during F2 period in Groups A and B, respectively. Conclusion: Curcumin, an active ingredient of turmeric is commercially available in gel form to treat different oral lesions and significantly effective in reducing spread and providing symptomatic relief in OLP without any adverse effects.
Keywords: Curcumin, erosive, lichen planus, reticular, ulcerative
|How to cite this article:|
Khaitan T, Vishal, Kabiraj A, Sinha DK, Ranjan R, Singh R. Curcuma longa in the treatment of symptomatic oral lichen planus: A non-randomized controlled trial. Indian J Dermatol 2022;67:478
|How to cite this URL:|
Khaitan T, Vishal, Kabiraj A, Sinha DK, Ranjan R, Singh R. Curcuma longa in the treatment of symptomatic oral lichen planus: A non-randomized controlled trial. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 2];67:478. Available from: https://www.e-ijd.org/text.asp?2022/67/4/478/360295
| Introduction|| |
Lichen planus (LP) is an inflammatory mucocutaneous disease, which can involve the skin, hair, nails, and mucosal surfaces. Oral LP (OLP) is one of the mucosal variants of LP, which tends to be chronic, often requiring long-term treatment and clinical surveillance. The pathogenesis of OLP is considered multifactorial. T-cell–mediated chronic inflammatory tissue reaction, genetic factors, stress, dental plaque and certain medications have been hypothesised as various etiological factors.,,,
Corticosteroids in systemic/topical form or intralesional injection remain the mainstay of treatment for OLP.,, Apart from steroids, systemic immunosuppressive agents such as azathioprine, cyclosporine, methotrexate, mycophenolate mofetil and thalidomide have also been used to treat patients with severe or refractory OLP, which also have significant adverse effects in the body. Other treatment modalities including oral and topical retinoids, hydroxychloroquine, doxycycline and metronidazole have also been tried with little success.
Oxidative stress has been suggested in the pathogenesis of OLP, therefore suggesting a dynamic role of antioxidants in its treatment. Antioxidants can be found naturally in many plants and vegetables and are beneficial in many pathological conditions. Turmeric is a native meditational plant having Indian origin and proven its anti-inflammatory, antioxidant properties and used as antibacterial, antimutagenic as well as anticancerous agent. Curcuma longa L. is the main chemical compound of the turmeric and has been used for hundreds of years as a flavour, colour and preservative. It has also been used in traditional system of medicine since thousands of years, but recently, it has attracted much attention as its antioxidant properties can have medicinal value.
Considering the above background, the present study was undertaken to evaluate the efficacy of curcumin clinically and statistically in the treatment of symptomatic OLP compared with a control group.
| Material and Method|| |
A non randomized controlled trial was performed after approval obtained from the institutional ethical committee. A total of 44 patients with symptomatic OLP were selected for the study based on convenient sampling and an informed written consent taken from all willing to participate. OLP was diagnosed clinically with typical features, that is, bilateral symmetric white striations or papules present and confirmed histopathologically after incisional biopsy. Patients already on corticosteroids therapy or any other medications (topical/systemic) taken for the same in the last 3 months and those not willing to participate were excluded from the study.
Total 40 subjects (26 females and 14 males) agreed to participate in the study, which were further divided into 2 treatment groups (groups A and B) with 20 patients each. Patients in group A (intervention group) were referred as curcumin group and treated with curcumin topical paste and a systemic multivitamin containing zinc, whereas patients in group B were given multivitamin containing zinc only (control group). Curenext oral gel (Abbott Pharma) containing 10 mg/g of curcumin was selected for the study. Patients were advised to dry the lesion in the mouth after having food and apply the ointment with a cotton tip applicator in the affected areas only, thrice daily. Both the curcumin group and the control group were also prescribed a standard multivitamin containing zinc for the study period.
The lesions were examined at starting of the treatment (day 0) also referred as base-day, after 4 weeks (day 28 ± 2) referred as F1 (first follow-up) and 12 weeks (day 72 ± 2) referred as F2 (second follow-up). All the readings obtained were noted in a proforma specially designed for the study. The findings were recorded according to semiquantitative REU (reticulation/keratosis, erythema, and ulceration) scoring system proposed by Piboonniyom. In this scoring system, 10 sites were categorized: (a) right buccal mucosa, (b) left buccal mucosa, (c) dorsal aspect of tongue, (d) ventral aspect of tongue, (e) maxillary gingiva, (f) mandibular gingiva, (g) floor of mouth, (h) hard palatal mucosa, (i) soft palate and tonsil and (j) labial mucosa. The severity of the lesions in each site was scored according to the presence of as follows:
- (R) reticular/hyperkeratotic lesions were scored from 0 to 1(weighted 2.0)
0 = no white striations
1 = presence of white striations or keratotic papules
- (E) erosive/erythematous areas were scored from 0 to 3 by area of involvement (weighted 1.5),
0 = no lesion,
1 = lesions <1 cm2
2 = lesions from 1 to 3 cm2
3 = lesions >3 cm2
- (U) ulcerative areas were scored from 0 to 3 by area of involvement (weighted 2.0).
0 = no lesion
1 = lesions <1 cm2
2 = lesions from 1 to 3 cm2
3 = lesions >3 cm2.
Score was determined with formula Σ (R × 2 + E × 1.5 + U × 2). A slight modification was made in case of involvement of multiple sites of OLP, the mean of the scores was calculated. The minimum score obtained was 0 and the maximum score 9.5.
Pain/burning sensation was recorded in a Visual analogue scale in the range of 0 to 10, with 0 having no symptoms and 10 having worst symptoms. Changes in R, E and U scores was recorded during F1 and F2 periods and statistically analysed with the help of SPSS 16.4 software using paired t test. Results were considered significant at P <.05.
| Results|| |
A total of 40 patients (26 females and 14 males) diagnosed with symptomatic OLP clinically and confirmed histopathologically participated in our study. The mean age of the patients was 38.4 years with range of 19 to 68 years. Clinically, the cases were categorised as Reticular form 21 (52.5%), Atrophic 7 (17.5%), Erosive 8 (20%) and Plaque 4 (10%) types [Table 1]. Out of the 10 intra-oral sites categorised, OL was found in buccal mucosa 31 (77.5%), dorsal and ventral surface of tongue 5 (12.5%), gingiva 3 (7.5%) and hard palate 1 (2.5%) case.
|Table 1: Distribution of the variants of oral lichen planus in the study period|
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In group A, 3 and 4 patients did not report during the periods F1 and F2, respectively. In group B, 3 and 5 patients were absent for follow-up period F1 and F2, respectively. Although, few patients had turned up for either the first or second follow-ups.
At the base-day, there was not much difference in the mean REU score, which was 4.49 and 4.5, respectively, in both the groups. During F1 period, 0.61 (group A) and 0.19 (group B) points improvement was noted, which further increased to 1.36 (group A) and 0.43 (group B) points in the F2 period. Variation of REU score is shown in [Table 2]. The readings were significant in both the follow-up periods with P <.01.
|Table 2: Mean difference of REU score on the base day, F1 and F2 periods|
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The mean pain/burning sensation score of group A and group B was 3.75 and 4.3, respectively at the base-day. Period F1 showed 1.71 and 0.71 reduction of the mean score, which further reduced to 2.88 and 1.24 during the period F2. Variation of burning sensation during follow-up is shown in [Table 3]. The readings were significant in both F1 and F2 periods with P <.01.
|Table 3: Mean difference of VAS score on the base day, F1 and F2 periods|
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[Figure 1] and [Figure 2] show the reduction of size of the lesion in the curcumin group after 12 weeks in the buccal mucosa and dorsal and ventral surface of tongue, respectively.
|Figure (a) Plaque type lichen planus on the dorsal and ventral aspect of tongue, (b) improvement in the size of lesion after 12 weeks|
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|Figure (a) Reticular type lichen planus on the right buccal mucosa, (b) improvement in the size of lesion after 12 weeks|
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| Discussion|| |
OLP is a nontobacco-induced keratotic lesion associated with stress. Clinically, it has specific and characteristic features: bilateral symmetric presentation showing a lace-like network of fine white lines (known as Wickham's striae) by which it can be easily identified. Although the World Health Organization has described OLP as a potentially malignant lesion but among all the variants of OLP, only its erosive form has potentially malignant properties, that is, 1% to 2% in the population. Several cases of OLP are usually an accidental finding during routine dental examinations as it does not cause any problem except for few who complain of pain and burning sensation associated with a whitish lesion and have chief concern to rule out oral malignancy. So, when a patient presents himself with OLP, main focus of an oral physician should be to monitor the spread and hope for self-remission and provide symptomatic relief. On the other hand, nonregressing lesions has to be addressed sooner than later.,
In our study, reticular OLP (52%) was the most prevalent form followed by erosive (20%), atrophic (17.5%) and plaque (10%) type. Buccal mucosa (77.5%) was the most common intra-oral site involved, whereas rest of the lesion were present in the dorsal surface of tongue (12.5%), gingiva (7.5%) and one in hard palate (2.5%). Many studies including Anderson (1968) and Tony (1987) had similar observation that reticular OLP is most common variant and buccal mucosa is the most common site, which was further validated in our study., We had encountered OLP in almost all the age groups except in the children with the youngest being 19 years and the oldest at 68 years of age. The mean age in our study was 38.4 years. Female predominance was noted in our study.
Cure of idiopathic lesion of oral mucosa has always been difficult due to lack of specific and universally accepted pathogenesis. In allopathy, corticosteroids are the mainstay of treatment. Corticosteroids in topical form such as clobetasol propionate, fluocinonide, betamethasone gel and intralesional triamcinolone acetonide (10 to 40 mg/mL) injections have been used for rapid clinical response., They have numerous side effects such as oropharyngeal candidiasis, telangiectasia and hypothalamic–pituitary–adrenal suppression. Oral physicians and avid researchers often go beyond the textbook and experiment with other alternative system of medicines like homeopathy and Ayurveda. Ayurvedic herbs are a key component of Ayurveda. Ancient Indian physician also known as Vaidya use more than 600 herbal formulas and 250 single plants remedies to treat various disease and conditions. Nevertheless, in our contemporary world, it is considered subclass and precious knowledge is being forgotten due to lack of implication and validation.
In one such example, during the year 1995, 2 nonresidential Indians at the University of Mississippi Medical Centre were granted U.S. Patent on Turmeric as a wound healing agent. The claim covered “a method of promoting healing of a wound by administering turmeric to a patient afflicted with wound”. By virtue of this patent, they gained the exclusive right to sell and distribute turmeric. This shocking incidence was fortunately revoked after the Council of Scientific and Industrial Research (CSIR), New Delhi, India, provided documentary evidence of traditional knowledge including ancient Sanskrit text and a article published in 1953, in the Journal of the Indian Medical Association. The patent was annulled in 1997, after ascertaining that there was no novelty. This incidence shows the importance of published documents and need to research in our indigenous knowledge.
The mechanism of efficacy of curcumin was studied by Tuba (2008). In his study of radicular properties of curcumin, he concluded that curcumin was an effective antioxidant in different in vitro assays including the following: reducing power, DPPH, ABTS, O2 and DMPD, radical scavenging, hydrogen peroxide scavenging and metal chelating activities when compared with standard antioxidant compounds such as BHA, BHT, tocopherol and trolox. Being an antioxidant, curcumin was well tolerated by all the patients and none of them reported with any allergic reaction. Unlike corticosteroids, curcumin-based medication can be prescribed for a longer duration of time and even in medically compromised patients.
In the present study, we had chosen a modified scale based on Piboonniyom scoring system to monitor OLP., It was found that the group of patients treated with curcumin had a significant decrease in REU score when compared with control group. During both F1 and F2 periods, patients had shown marked reduction in the size and severity of the lesion. Singh et al. in a pilot study had shown beneficial effect of curcumin in OLP. Later, Kia et al. in a comparative study found that 36% of patients treated with curcumin had complete remission of the lesion and was equally beneficial as triamcinolone.
Another significant finding was symptomatic relief to the patients in the curcumin group as the present study focussed on symptomatic OLP cases. A total of 31.25% of the patients got complete relief, whereas the remaining reported with partial improvement in pain and burning sensation, which was statistically significant. These properties of curcumin have been evaluated in studies of various skin and mucosal lesions. Farjana et al. found that curcumin was effective in reducing the compliance in the patients with gingivitis. Kuttan et al. performed a curcumin-based study on external cancerous lesions and found 90% of the patients had symptomatic relief like pain and itching.
| Conclusion|| |
Curcumin is naturally found in turmeric and a common household spice. The availability in the form of oral gel has opened the door of various researches for the treatment of oral diseases, which could not be effectively treated with routine textbook treatment. This study showed that curcumin can be potentially used in the treatment of symptomatic OLP. Further studies should be done on larger scale to validate the finding of our research.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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